Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form issued by the Arizona Department of Child Safety (DCS). The form is designed for contractors providing congregate care services to request the retention of a child's bed during temporary absences for specific reasons such as AWOL, detention, extended visits, hospitalization, or other circumstances.

The form allows contractors to request bed holds for up to 7 days with approval from the Statewide Placement Program Manager, or up to 14 days with the Statewide Placement Program Administrator's signature. The document requires detailed information about the child, including their name, Personal Identification (PID) number, and the specific reason for the bed hold. Completed forms can be submitted electronically to BedHold@azdcs.gov, and the form includes signature lines for both the contractor and the Statewide Placement Program Manager/Administrator to authorize the bed hold.